Sexual and gender minorities, including people who identify as lesbian, gay, bisexual, or transgender (LGBT), are at increased risk for a number of health threats including depression, tobacco and substance use, injury, violence, and communicable diseases.^1-4 Dissatisfaction with and avoidance of routine health care can put sexual and gender minorities at additional risk for poor health.^1,2 Factors that may deter LGBT individuals from seeking needed health services or, when they do access health care, from disclosing their sexual identity or behavior include: an unwelcoming clinic environment, assumptions that patients are heterosexual, and clinician discomfort with discussing sexual history and behavior.^1-3

Strategies that can improve the health care experience and, ultimately the health, of LGBT people include making the clinic environment and clinical encounter more inclusive, training staff about the impact of bias and stigma on patient health, and being knowledgeable about local LGBT resources.^1,2 Examples of these strategies, as well as a selection of local resources, are listed below.

Note: While recommendations for addressing youth-specific LGBT issues are beyond the scope of this article, the actions below can be applied to improve the clinic experience for both youth and adults.

Make the Clinic Environment Welcoming

• Place LGBT pride symbols (e.g., rainbow flags and pink triangles) prominently in clinic areas such as entrances and registration.
• Make clinic publications, websites, and social media inclusive by incorporating photos of same-sex couples and LGBT pride symbols and by using appropriate terminology.
• Provide access to clearly labeled gender-neutral restrooms.
• Train office staff to use gender-neutral, LGBT-friendly terminology.
• Make intake forms inclusive, for instance:
  • Include 2-step gender questions⁴:
    1. What sex were you assigned at birth, on your original birth certificate?

       (i.e., male or female)

    2. How do you describe yourself? (check one)

       (i.e., male; female; transgender; do not identify as male, female, transgender)

  • Include a question about sexual identity (e.g., “Do you consider yourself to be straight, lesbian, gay, bisexual, questioning/unsure, or decline to share?”).
  • Give a choice of preferred pronouns (e.g., he/she, her/him, they/them).
  • Collect patient’s preferred first name (if different from the legal name).
  • For marital status questions, include alternatives to “married” and “single” (e.g., “partnered” or “committed relationship”).
  • On pediatric intake forms, provide space for same-sex parents to record the names of both parents (vs. “mother’s name” and “father’s name”).

Make the Clinical Encounter Welcoming

• Don’t make assumptions that a patient is heterosexual or that a patient who identifies as straight has sex exclusively with people of the opposite gender.
• Use gender-neutral, non-judgmental language when discussing marital/relationship status, sexual identity, and sexual behavior.
• Establish trust and discuss confidentiality, including what types of information will be included in the medical record and what may be shared.
• Take a sexual history routinely on all patients. Don’t make assumptions about which patients are low or high risk. Normalize and generalize the sexual history, for instance, start with, “These are questions I regularly ask all my patients…”. See Performing a Sexual Risk Assessment for more guidance on how to take a sexual history.
• Understand and use appropriate terminology. Using respectful language is an important step for making a safe space for LGBT patients. If you are not familiar with a term used by a patient, ask for clarification.

Educate Yourself and Your Staff

• Facilitate training for all staff (including clinical) on implicit bias* and stigma and how they affect patient care.

* Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. Consider taking a Harvard Implicit Bias Test. See Additional Learning for more resources.

Be Knowledgeable About LGBT Community Resources

Health care providers should be ready to refer patients to community-based resources that offer a welcoming, culturally competent environment for LGBT individuals. The following is a selection of local and national resources for LGBT patients.

Addiction Services

• Los Angeles County Substance Use Services Find LGBT-friendly substance use services and bed availability using the online dashboard or by calling the helpline.  Services include outpatient and intensive outpatient treatment, residential treatment, withdrawal management, opioid treatment programs, and recovery bridge housing. The online dashboard tool can be filtered for clients served, including Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex, Asexual (LGBTQIA) individuals.  
  • Services and Bed Availability Tool
  • Substance Abuse Service Helpline: 844-804-7500
• Los Angeles LGBT Center Addiction Recovery Services
  • Anonymous online chat support every weekday from 1 p.m. to 5 p.m.
  • Therapy: one-on-one and group
  • Hosts 12-step group meetings
• Los Angeles LGBT Center Freedom from Smoking Group Therapy

Intimate Partner Violence

• 24-hour National Domestic Violence Hotline: 800-799-SAFE (7233)

• Los Angeles LGBT Center Intimate Partner/Domestic Violence Program 323-860-5806
  Email: domesticviolence@lalgbtcenter.org

• Domestic Violence Shelters: List curated by the Los Angeles LGBT Center.

Mental Health

All Ages

• LGBT National Help Center Hotlines www.glbthotline.org

  Free and confidential peer-counseling, information and local resources.
  All AGES: 888-843-4564 for youth and adults
  ELDER: 888-234-SAGE (7243) for seniors

• Los Angeles LGBT Center Mental Health Services https://lalgbtcenter.org/health-services

Youth-Specific

• LGBT National Youth Talkline https://www.glbthotline.org/youth-talkline.html 800-246-PRIDE (800-246-7743)
  Provides free and confidential peer support.


• Los Angeles LGBT Center RISE (Recognize Intervene Support Empower) https://lalgbtcenter.org/rise/resources
  Resources for foster youth.


• The Trevor Project https://www.thetrevorproject.org 24 hour hotline 866-488-7386
  A national organization focused on crisis and suicide prevention among lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth.

Transgender Support Services

• Center for Transyouth Health and Development, Children’s Hospital Los Angeles  https://www.chla.org/the-center-transyouth-health-and-development.
  Medical intervention, mental health, health education, and peer support services for transgender youth.


• Transgender Health Program, St. John’s Family and Child Center http://www.wellchild.org/transgender-health-program/
  Name/gender marker change clinic, victim support services, job readiness workshops, and drop-in transgender community night.


• TransLatin@ Coalition https://www.translatinacoalition.org/
  Drop-in center, food distribution, economic and workforce development, ESL classes, and services for immigrants.  


• Trans Wellness Center https://mytranswellness.org 323-993-2900
  Resources for transgender and non-binary people offered by six local community organizations including hormone therapy and transition resources, HIV testing and care, mental and sexual health services and education, occupational training, housing services, and legal services.

General Resources

Free and confidential peer-counseling, information and local resources.

• AIDS Healthcare Foundation https://www.aidshealth.org/

  AIDS/HIV prevention counseling, STD and HIV testing, comprehensive HIV medical care, care/case management, and clinical trials. 

• AIDS Project Los Angeles (APLA) Health https://aplahealth.org/ 

  Services for people living with HIV/AIDS including benefits counseling, home health services, housing support services, and a food pantry. Programs to support young men of color including workshops, outings, and incentivized groups.

• Asian Pacific AIDS Intervention Team http://apaitonline.org/services-2/  

  HIV testing and education, substance use programs, counseling, and support groups including LGBT-focused support groups.

• Bienestar https://www.bienestar.org/about-us/ 

  Services focused on emerging health issues faced by Latino and LGBTQ populations, including prevention education, housing services, a food bank, and support groups including LGBT-focused groups.

• Los Angeles LGBT Center https://lalgbtcenter.org

  The LA LGBT Center provides many programs and services including a variety of health and mental health care services as well as social services and housing.

• LGBT National Help Center Hotlines www.glbthotline.org

  Free and confidential peer-counseling, information and local resources.
  All AGES: 888-843-4564 for youth and adults
  ELDER: 888-234-SAGE (7243) for seniors

• Transgender Health Program Community Resource Guide http://www.wellchild.org/St-Johns-Trans-Resource-Guide-June-2017.pdf

  A listing of local resources, including addiction services, food pantries, HIV/AIDS services, homeless services, legal services, mental health services, and LGBTQ community centers.

Additional Learning

• Center of Excellence on Racial and Ethnic Minority Young Men Who Have Sex with Men and Other Lesbian, Gay, Bisexual, and Transgender Populations (YMSM+LGBT CoE) http://www.ymsmlgbt.org/
  This center provides training and technical assistance resources, including training curricula, webinars, and an online clearinghouse to help providers working with LGBT populations and racial/ethnic minority young men who have sex with men (ages 18-26).


• About LGBT Health: Centers for Disease Control and Prevention Website


• GMLA (previously known as the Gay & Lesbian Medical Association): Cultural Competence Webinar Series - Quality Healthcare for Lesbian, Gay, Bisexual & Transgender People. The webinars are free and include content that has broad relevance to clinicians, administrators, researchers and academics alike. All are encouraged to view the archives.
  • Part 1: Understanding the Health Needs of LGBT People: An Introduction
  • Part 2: Creating a Welcoming and Safe Environment for LGBT People and Families
  • Part 3: Clinical Skills for the Care of Transgender Individuals


• Harvard Implicit Bias Test: https://implicit.harvard.edu/implicit/takeatest.html


• Health and Access to Care and Coverage for LGBT Individuals in the U.S. This updated issue brief from the Kaiser Family Foundation provides an overview of what is known about LGBT health status, coverage, and access in the United States, and reviews the implications of the ACA, the Supreme Court rulings on marriage equality, and other recent policy developments for LGBT individuals and their families going forward.


• MSM Sexual Health Standards of Care: Addressing the Sexual Health Crisis among Gay, Bisexual and Other Men who have Sex with Men. A report from the National Coalition of STD Directors.


• Addressing Stigma: A Blueprint for Improving HIV/STD Prevention and Care Outcomes for Black and Latino Gay Men. This report from NCSD and NASTAD provides recommendations to help health centers reduce stigma around sexuality, race, and gender identity in order to enhance HIV/STD prevention services for Black and Latino MSM.        

References

1. Mayer KH, Bradford JB, Makadon HJ, et al. Sexual and Gender Minority Health: What we Know and What Needs to be Done. Am J Public Health. 2008;98(6):989-995. https://oied.ncsu.edu/selc/wp-content/uploads/2013/05/Sexual-and-gender-minority-health-what-we-know-and-what-needs-to-be-done.pdf. Accessed March 20, 2018.
2. Knight DA, Jarrett D. Preventive Health Care for Men Who Have Sex with Men. Am Fam Physician. 2015;91(12):844-852. https://www.aafp.org/afp/2015/0615/p844.html.
3. National Coalition of STD Directors. MSM Sexual Health Standards of Care: Addressing the Sexual Health Crisis among Gay, Bisexual and Other Men who have Sex with Men (MSM). http://www.ncsddc.org/wp-content/uploads/2017/08/MSM-Sexual-Health-Standards-of-Care-2017.pdf. Accessed December 10, 2017.
4. Guerry, S. Summary of Los Angeles County Recommendations for Preventing Communicable Diseases in Men Who Have Sex with Men. Rx for Prevention. 2018;8(1). http://rx.ph.lacounty.gov/RxMSM0118. Accessed April 27, 2018.
5. JL Herman; The GenIUSS Group, The Williams Institute. Best Practices for Asking Questions to Identify Transgender and Other Gender Minority Respondents on Population-Based Surveys. https://williamsinstitute.law.ucla.edu/wp-content/uploads/geniuss-report-sep-2014.pdf. Published September 2014. Accessed April 3, 2018.